Case 19: Breast Lump. Expert comment from Miss Pippa Hayes

Thanks to everyone who contributed to the discussions about Mrs Johnson an 88 year old lady who had a breast lump.

DSC_0187 

This week’s question setter & expert was Miss Pippa Hayes, ST7 Surgery. 

Information available at the start of the week:

Mildred Johnson is an 88 year old woman referred to the Breast Surgical Outpatient Clinic by her GP. She has a lump in her left breast.

HPC

Mrs Johnson is accompanied to the consultation by her daughter Elizabeth who discovered the lump while helping her to try on some new clothes and insisted she attend the GP surgery. Mrs Johnson admitted that she had noticed the lump ‘some months’ before but did not want to worry anyone by mentioning it. She denies any pain and insists that she does not want any treatment but her daughter is very worried and wants the lump to be ‘taken out’ as she had a friend who died from Breast Cancer and is worried that this may be the same problem.

PMH

CABG x4 10 years ago, TIA 8 years ago, HTN, COPD, T2DM, Hypothyroidism, Appendicectomy 70 years ago, OA, Mild short term memory loss

DH

Amlodipine 5mg OD PO

Bendroflumethiazide 2.5mg OD PO

Ramipril 2.5mg OD PO

Tiotropium II OD INH

Salbutamol II INH PRN

Metformin 500mg TDS PO

Levothyroxine 150mg OD PO

Allergies: Penicillin (rash)

FH

Nil

SH

Non-smoker

Occasional ETOH

Widowed and lives on her own in warden-controlled accommodation with daughter close by

Independent with ADLs

Mobilises with stick

O/E

Mrs Johnson is alert and orientated to place, time and person.

She has a non-tender 2x2cm lump in the left breast upper outer quadrant with slight tethering of the overlying skin; the skin itself is normal in appearance. There are palpable non-tender lymph nodes in the left axilla. The right breast/axilla normal.

Question 1:What is the differential diagnosis?

Further information released during the week:

Further questions discussed on Twitter:

Question 2:  What initial investigations should be completed?

Investigations reveal:

The mammogram report describes an isolated lesion in the left breast upper outer quadrant measuring 2 by 2 cms immediately deep to the skin graded M5. The US scan confirms this and  additionally comments on malignant-appearing lymph nodes in the left axilla. The histology report is of a Grade 2 Invasive Ductal Carcinoma B5b with associated high-grade DCIS (Ductal Carcinoma in Situ) which is ER (Oestrogen Receptor) positive 8/8, PR (Progesterone Receptor) positive 8/8 and HER2 (Herceptin Receptor) negative.

Question 3: What are the management options?

Expert Comment

Key points:

  1. Initial assessment of breast lump (triple assessment)
  2. Assessment of fitness for surgery/General Anaesthetic
  3. Patient choice/autonomy

Resources:

ABC of Breast Disease

American Society of Anaesthesiologists Physical Status Classification

GMC Consent Guidelines (in Good Medical Practice)

Miss Pippa Hayes, ST7 General Surgery says:

This was an interesting scenario which brought out some important points about the management of breast lumps.

This is a common presentation in the GP surgery, the Accident and Emergency department and the surgical Outpatient Clinic.

Many patients do not wish to undergo surgical treatment but may not be aware of alternative options. Often family members’ views differ from those of the patient. It is important to take the wishes of the patient into consideration when planning their treatment.

What Happened:

Mrs Johnson undergoes full triple assessment (examination, mammogram, US scan and core biopsy) and returns to the clinic one week later.

The mammogram report describes an isolated lesion in the left breast upper outer quadrant measuring 2 by 2 cms immediately deep to the skin graded M5. The US scan confirms this and  additionally comments on malignant-appearing lymph nodes in the left axilla. The histology report is of a Grade 2 Invasive Ductal Carcinoma B5b with associated high-grade DCIS (Ductal Carcinoma in Situ) which is ER (Oestrogen Receptor) positive 8/8, PR (Progesterone Receptor) positive 8/8 and HER2 (Herceptin Receptor) negative.

At her second consultation in the clinic Mrs Johnson undergoes a mini-mental state examination (MMSE) and scores 9/10, dropping one point for naming the Prime Minister incorrectly

Differential Diagnosis 

The most common differential diagnoses for a lump in the breast include:

– prominent glandular tissue (normal breast tissue) with no abnormality

– breast cyst – these are characteristically tender and fluctuant/mobile

– fibroadenoma – these may be tender, although are not always, and are often mobile

(historically these were known as ‘breast mouse’ as were often difficult for both patient and

doctor to locate!)

– malignant lump (cancer)

Breast Lump Grading

The examination, radiological and histological/cytological grading systems for breast lumps is a universal language used by doctors from these different specialties to denote the nature of their findings in numerical form; the lump is graded from 1 to 5 using the following lettering system:

Examination: P

Mammogram: M or R

Ultrasound scan: U

Cytology: C

Biopsy: B

With common values for each modality of test, the numerical grades imply the following:

1: normal/NAD

2: benign abnormality

3: indeterminate

4: suspicious of malignancy

5: definite malignancy

The radiological grading of Mrs Johnson’s breast lump was M5/U5 and the subsequent biopsy (histology) B5b; these test findings therefore describe a breast cancer. Histological B5 gradings are further sub-divided to differentiate between Ductal Carcinoma In Situ (DCIS) which is graded B5a and Invasive Ductal Carcinoma (IDC) which is, as here, B5b. When there is DCIS in association with IDC, the higher grade (B5b) is applied as the overall result.

Treatment Options

Patients may not be fit for General Anasthesia, in which case it is important to look at alternative options to surgical treatment.

An alternative treatment option for Breast Cancers which are hormone-positive is tablet medication in the form of Tamoxifen or aromatase-inhibitors as first-line treatment; in many patients this will reduce the size of the breast cancer, or prevent it from developing further, sometimes beyond the natural life-span of the patient and so should be considered as primary treatment in those unfit or unwilling to undergo surgery under General Anaesthesia.

Patients, fit or otherwise, may choose not to undergo surgical treatment and have the right to refuse this providing that they are Gillick Competent. Short term memory loss or mild dementia does not necessarily imply that a patient is not competent to make decisions regarding their treatment – Mrs Johnson lives alone and independently and therefore has the right for her wishes to be adhered to, providing that competence is shown, regardless of the conflicting wishes of her family.

 

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